Chronic Pain Chronicles with Dr Karmy
Join Dr. Grigory Karmy M.D., a distinguished chronic pain management physician with over 20 years of experience, on a captivating journey through the world of pain relief in his podcast series. Delving into the latest regenerative medical treatments like PRP, stem cell injections, and prolozone therapy, alongside educational discussions on pain transmission and various medical options, Dr. Karmy shares invaluable insights and real-life stories, empowering listeners to find relief and regain control over their chronic pain.
Chronic Pain Chronicles with Dr Karmy
Episode 3: Nerve Blocks in Chronic Pain Management - How Nerve Blocks Can Help Manage Your Pain?
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Nerve blocks are the most common procedure performed for chronic pain management in Ontario. Over 55,000 patients receive this treatment every year. Yet despite the widespread use of this procedure, there is some controversy about this approach.
Nerve blocks happen to be one of the first procedures Dr. Grigory Karmy learned to perform. In this episode, Dr. Karmy will share what he has learned after performing nerve blocks for over 20 years on patients with a wide variety of chronic pain conditions.
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In terms of the kinds of chronic pain conditions that can be treated with nerve blocks, the list is very long. Pretty well any musculoskeletal condition treated with nerve blocks that includes spine problems, that include joint problems, that include muscle problems.
Raveena:Welcome to Chronic Pain Chronicles with Dr. Karmy, where we unravel the intricate world of nerve blocks, exploring their fascinating science, diverse applications, and profound impact on pain management. I'm your host, Raveena, and I invite you to join me on this journey through the neural pathways that shape our understanding of pain management, anesthesia, and beyond. Nerve blocks hold the power to intercept pain signals and is a common form of treatment that provides relief to patients managing chronic pain. Yet behind their seemingly simple concept lies a complex interplay of anatomy, pharmacology, and clinical expertise. So join me as we embark on this voyage through the realm of nerve blocks. We're joined by Dr. Karmy, an expert in pain management with over 20 years of medical experience.
Dr Karmy:Hi, this is Dr. Karmy, and I just wanted to discuss briefly nerve blocks. The reason, of course, is that we use nerve blocks extensively at the clinic. I have a soft spot for nerve blocks because this is the first type of pain procedure that I learned when I entered the field, but also because there's a lot of misunderstanding around nerve blocks and when they're used and how they're used. And I just wanted to clarify all that. First of all, what are nerve blocks? Well, nerve blocks are injections of local anesthetic, , around nerves. that go to painful areas. Typically they are not used in isolation, but combined with trigger point injections into muscles, joint injections, and tendon sheath injections. The goal of nerve block injections is to reduce pain, and that is where the first misunderstanding often occurs, because nerve blocks involve using local anesthetics and most of us are familiar with local anesthetics that are used during some dental procedures or if you have a cut that needs to be stitched up, injected around the wound and so there's an impression that the effect of local anesthetic is very, very short term, a few hours and then the effect is gone. So some patients, when they come into the clinic and I start talking about nerve blocks, they kind of don't see the point. Are you trying to just nb the area for a few hours and then the pain is going to be back? And when we are using them in chronic pain management. We're using them for very different reasons. So in addition to nbing effect, local anesthetics have other properties. They can reduce inflammation, not to the same degree as cortisone injections, but they can still, they still have that effect. They also reduce muscle spasm. In particular, , trigger point injections are used in patients with myofascial pain. Also with chronic pain, there's several mechanisms involved, but one of the mechanisms is called central and peripheral sensitization, where essentially nervous system becomes too responsive to signals to the point that it starts to interpret signals that are not associated with tissue damage as tissue damage. So in other words, because of the sensitization, even gentle pressure can cause pain signals to go to the spinal cord and the brain. There's some discussion as to how much of sensitization comes from the periphery. In other words, the muscle and skin, and how much of the sensitization is at the spinal cord level, and how much of it is at the brain level. However, there is some evidence to show that breathing sensitization at the periphery, in other words, in the muscle, can actually also reduce. central sensitization in the spinal cord as well as in the brain. So potentially free mechanisms of action reduces inflammation, reduces muscle spasm, and perhaps desensitizes pain generators so that they don't send so many pain signals. So when we're treating a patient with chronic pain, we're not really trying to nb. the pain for a few hours, we're hoping to get some of those other benefits. And those other benefits can last longer. How much longer? Depends on the patient. Typically, days to maybe a week or two. Although if somebody is very responsive to the treatments, sometimes one or two treatments is all they need and the pain goes away. Again, it's very individual. First of all, not everybody responds to nerve blocks. My impression is that maybe about 30 to at the most 50 percent of patients respond to nerve blocks. The rest don't. They get that initial nbing effect for a few hours, but then the back pain is back to square one again. Second of all, nerve blocks and trigger point injections is generally a gradual treatment. In other words, typically you don't just go in once and you get your nerve block and you are good for years. Like physiotherapy, it's multiple visits, typically once a week. And initially the effect is smaller and shorter, maybe days, but then over time the effect becomes bigger and stronger. Also, what I find is that even within a single patient, some areas of pain may respond well to nerve blocks and some don't. Having said all of that, after you have treated the patient for a period of time, anywhere from two months to four months to six months, patients basically split into three categories. One category is patients who don't respond, and usually by about treatment four, five, if the patients are not getting more than 24 hours of response, chances for them responding for longer period of time in the future is pretty small. Again, it's not zero, but it becomes a lot smaller. Then we have patients who who respond very, very well. So these are the patients who might have five or six or eight visits, and then often I don't see them for years and years and years. And then there's patients that fall in between, and the patients that fall in between typically will have a response that can last days. and sometimes a week or two. But if you space out the treatments any farther than that, then the pain starts to go back to square one again and becomes severe. What about risks and side effects of this procedure? Well, first of all, something to keep in mind is any time you see a medical doctor and they put you on a tablet or they do a surgery on you or they do injections on you, the risk is always higher than if you just go to the doctor. to, a physiotherapist or a massage therapist, , because physiotherapy, massage therapy, they don't put anything into your body. The risk of side effects is essentially zero. Once you start seeing a medical doctor, the question is how serious the risk is. And also, how likely is it for that risk to occur? The nice thing about nerve blocks is the chances for the severe complications, and we're talking infection because you're putting injection through the skin, and there's bacteria that normally live in the skin that we, of course, try to get rid of, but can never guarantee that the bacteria are all gone. or let's say life threatening allergic reaction to local anesthetic or some kind of a major problem with a heart rhythm chances for those things happening is very very low. Then we have minor side effects and the minor side effects are much more common, but they are minor. So some patients will find their blood pressure drops or their blood pressure goes up for 5 10 minutes after the treatment. Some patients find that they get dizzy or they get nauseated or they get sleepy after the treatment. Dizziness and nausea typically happen right away and goes away after 5 10 minutes on occasion. Dizziness and nausea can start a little bit later, let's say 10 15 minutes later, and occasionally it can last longer, up to an hour. There's an occasion post injection pain due to bruising of the muscles. And by the way, for most of nerve blocks, the needle tip just sits in the muscle and spreads to nearby nerves. In any case, if there's post injection pain. Typically it goes away after a couple of days. If you are very unlucky, sometimes it can take up to two weeks for the pain to go away., so that's the main side effects. Just to put it into perspective, nerve blocks are safer than cortisone injections. They're infinitely safer than something like a knee replacement surgery. And in some ways there's advantage over medications because it's an injection. So the medicine mostly stays in the muscle that's being injected a little bit, gets into the circulation, but very, very little. And the medication clears your body within 24 hours. Of course, if you think of tablets, well, they have to be in the body 24 7 in order to control pain. Tablets do not preferentially stay in the targets that are causing pain. Tablets go throughout your whole body, including the liver, the kidney, the brain. The other good aspect of nerve blocks is that it is an OHIP covered service. A lot of patients with chronic pain, on limited income, often they lost their jobs because of their pain. Also with chronic pain, whatever treatment you use, You typically have to repeat it many times, which means that the risks add up over time and the costs add up over time. So if one is able to control their pain with treatment which is both free to the patient and relatively low risk, it is certainly an advantage if the treatment works. In terms of the kinds of, chronic pain conditions that can be treated with nerve blocks, the list is very long. Pretty well any musculoskeletal condition can be treated with nerve blocks that include spine problems, it includes joint problems, it includes muscle problems, even migraines. There's actually very strong evidence for using nerve blocks to treat migraines. So given that nerve blocks can be used for so many different chronic pain conditions, do I always start with nerve blocks? No, not always. There are some conditions that tend to respond better to other approaches, and although nerve blocks can work for them,, chances for them working are lower. Also, sometimes it's not practical to use nerve blocks. So certainly some people are trying to avoid steroids and cortisone, and I will use nerve blocks. In these patients, I will often try treating patients with widespread pain with nerve blocks., nerve blocks is a very safe treatment, which I can do frequently. Patients with widespread chronic pain often have many different pain generators. And, , in order to cover them all, often I have to have multiple visits. Also, sometimes through doing nerve blocks, I figure out which sources of pain or which pain generators are more important than others. Some areas often don't respond well to nerve blocks, , although the chances of response are not zero. For example, heel pain due to plantar fasciitis tends to respond to cortisone much better than nerve blocks. Lateral epicondylitis or tennis elbow, again another example of inflammation of the tendons, will respond better to cortisone than nerve blocks. Knees. and I would say joints in general will often respond better to cortisone than to nerve blocks. So, nerve blocks are not always a problem. The first line, you look at things like how likely is the patient to respond to nerve blocks. You also look at practicalities. If someone isn't able to come to the clinic, , on frequent basis because they live so far away, then nerve blocks is probably not the right thing. treatment for them. Also, as I mentioned, nerve blocks often is a gradual treatment where you are getting a very gradual improvement. So, if somebody comes in and they are in excruciating pain, often, they are not able or willing to wait for two months before the pain settles down. They want something faster and quicker, and again, typically cortisone is what I use. Another point I wanted to make is that no chronic pain treatment works well in isolation. And this includes nerve blocks. Nerve blocks can reduce severity of the pain in the right patient. But often this doesn't translate into improvement in function. What I find is a lot of patients are,, afraid to exert because they are worried that it might aggravate their pain. A lot of patients, because they've had chronic pain for a long time, their muscles become stiff, they become weak, , their endurance goes down, their energy level goes down, And so it is really important to use that pain reduction that nerve blocks afford to push the exercise program. Now you don't want to exercise during the first, , 12 hours after the nerve block and that is because the muscles can become weak or and temporarily. And so a patient is more likely to injure themselves while exercising. However, during the following day and onwards, exercise is very, very important. And there isn't just one type of exercise. That's right. You need some exercises for flexibility. Some exercises too you increase strength and some exercises to increase endurance, and you want to progress the intensity and duration of these exercises from month to month. Now the progress may be much slower than patients would like. who don't have chronic pain and also sometimes you will overdo it and you will know that because the pain will go up and stay up not just for a few hours but a nber of days. But through trial and error most patients find the right rate of progress and the right exercises to do. The other the important thing is to set goals, , whether that goal can be as simple as being able to clean the house, or it can be as simple as going for a walk, or it can be getting back to some of the activities that they enjoyed doing in the past, or it can be going back to work. The treatment is gradual and because pain fluctuates up and down in everybody with chronic pain, depending on weather, stress, activity levels, , diet, et cetera, it is very hard to see progress. Unless you keep, you set goals and you keep track on how you are progressing towards those goals. So, looking into the future, what do I see happening in the future with nerve blocks? Well, there is a trend towards using imaging when doing nerve blocks. It is especially promoted by academic anesthesiologists. Typically, it's either ultrasound or x ray. With ultrasound, I would say, gaining more prominence just as a very broad blanket statement for so , most nerve blocks, ultrasound is unnecessary, and if anything, does more harm than good. If there isn't a good way of using landmarks, and by landmarks I mean bones, muscles, to figure out where the nerve runs, then ultrasound is necessary. It does have an advantage over landmark based procedures, so used selectively, used in cases where maybe patient didn't respond to a set of nerve blocks, I can see use of ultrasound guidance, and I do use ultrasound guidance in my practice on selected cases. The downside with ultrasound is it requires much bigger, thicker needles, which can cause a lot more tissue trauma, which in turn will cause some additional pain., and because typically we do nerve blocks repeatedly over the course of six to eight visits and sometimes much more than that., the amount of trauma and pain caused by nerve blocks needles used for ultrasound injections would be quite significant. Also, it's another foreign body in your sterile field, so I would imagine the risk of infection, , or goes up a little bit. So, like anything else in pain, I think it has some future, but I don't see it becoming a requirement for every single procedure. In terms of x rays, the issue is radiation exposure. You can't practically expose somebody to radiation many times a year. Even if it makes your needle marginally more accurate, the thing about chronic pain is by definition it is chronic. So these procedures are repeated over and over and over again. And although exposure from a single, radiation exposure from a single x ray may not be that large over the course of multiple years, the radiation exposure does add up. More importantly X ray guidance does not protect against more serious complications of these procedures, which are things like infection or bleeding, X ray cannot see blood vessels., and again, primarily x rays are used for procedures around the lumbar spine. They tend not to be used much for other types of, , procedures. I anticipate that Ontario government will likely try to control how often nerve blocks are done and reduce the compensation for the doctors who perform those procedures. So that's a constant that always hanging over the field and will likely continue to hang over the field indefinitely. The only way to protect the field is through action by patients who are benefiting from this procedure. And there are tens of thousands of patients across Ontario who are benefiting from these procedures. And as long as they speak up, anytime the government tries to change the coverage, I think that procedures will be preserved. I also think that we need more studies on nerve blocks to prove to medical society in general and the governments that these treatments work. There are a number of studies on nerve blocks already, especially on nerve blocks for headaches. However, the more studies we have, the less likely that we'll be vulnerable to the attacks from the government and from some of the academic anesthesiologists who disparage the field.
Raveena:Thank you for listening to the third episode of Chronic Pain Chronicles with Dr. Karmy, a podcast which explores chronic pain from a physician's point of view. In our episodes, we intend to explore some of the most effective and commonly used approaches to managing chronic pain, including nerve blocks and regenerative medicine approaches. We intend to educate on the causes of chronic pain and understand where the field is going in the future. I am Raveena Aujla. Till next time. Disclaimer, when it comes to your health, always consult with your own physician or healthcare provider for personalized advice and guidance. The information provided in this podcast is for educational and informational purposes only and should not be considered medical advice or a substitute for professional medical care.
